Correlation Between Peripheral White Blood Cell Counts And

Int. J. Med. Sci. 2013, Vol. 10 758

Ivyspring International Publisher International Journal of Medical Sciences 2013; 10(6):758-765. doi: 10.7150/ijms.6155 Research Paper Correlation between Peripheral White Blood Cell Counts and Hyperglycemic Emergencies Wei Xu1,2 ,∗, Hai-feng Wu3,∗, Shao-gang Ma2,∗, Feng Bai2, Wen Hu2, Yue Jin4, Hong Liu2

1. School of Medicine, Southeast University, Nanjing, Jiangsu 210009, China; 2. Department of Endocrinology, the Affiliated Huai'an Hospital of Xuzhou Medical College, Huai'an, Jiangsu 223002, China; 3. Department of Critical Care Medicine, the Affiliated Yixing People’s Hospital of Jiangsu University, Yixing, Jiangsu 214200, China; 4. Department of Clinical Laboratory, the Affiliated Huai'an Hospital of Xuzhou Medical College, Huai'an, Jiangsu 223002, China.

∗ Co-first authors.

 Corresponding author: Shao-gang Ma, Ph.D., M.D. Address: No. 60 South Huaihai Road, Huai'an 223002, China E-mail: [email protected] Fax/Phone: +86-517-8394 3591.

© Ivyspring International Publisher. This is an open-access article distributed under the terms of the Creative Commons License (http://creativecommons.org/ licenses/by-nc-nd/3.0/). Reproduction is permitted for personal, noncommercial use, provided that the article is in whole, unmodified, and properly cited.

Received: 2013.02.26; Accepted: 2013.04.10; Published: 2013.04.18

Abstract Objective: To determine the correlation between differential leukocyte counts and hyperglycemic emergencies. Methods: Fifty patients with diabetic ketoacidosis (DKA), 50 patients with diabetic ketosis (DK), 50 non-DK diabetic patients with stable glycemic control, and 50 normal controls were enrolled. Their total and differential leukocyte counts were measured and evaluated at admission and after treatment. Results: The patients with DKA and DK had higher plasma glucose levels (20.84±6.73 mmol/L, 15.55±2.6 mmol/L, respectively) and more median leukocytes (13325/mm3 and 6595/mm3, respectively) and median neutrophils (11124 /mm3 and 4125/mm3, respectively) but fewer median eosinophils (28/mm3 and 72/mm3, respectively) compared to non-DK and control groups (all p < 0.05). Acute infection increased the elevating extent. The median leukocyte counts in DK and non-DK patients (6595/mm3 and 6008/mm3, respectively) were within the normal range. The counts of total leukocytes and neutrophils were significantly higher but eosinophils lower in severe DKA cases than in mild/moderate cases (p < 0.05). When the DKA and DK and infection resolved, total leukocytes and neutrophils fell, but eosinophils increased. The counts of total leukocytes, neutrophils, and monocytes were negatively correlated with arterial pH levels (r = −0.515, r = −0.510, r = −0.517, all p < 0.001, respectively) and positively correlated with plasma glucose levels (r = 0.722, r = 0.733, r = 0.632, all p < 0.05, respectively) in DKA patients. The arterial pH level was the most significant factor affecting total leukocytes in DKA (β = 0.467, p = 0.003). The diagnosis analysis showed that higher total leukocyte and neutrophil counts and lower eosinophil counts had a significant ability to reflect the presence of hyperglycemic emergencies. Conclusion: More total leukocytes and neutrophils but fewer eosinophils was significantly correlated with DKA and DK. Leukocyte counts can add valuable information to reflect the presence of hyperglycemic crisis and acute infection.

Key words: Diabetic ketoacidosis, Diabetic ketosis, Leukocytes counts.

1. Introduction Diabetic ketoacidosis (DKA) is a common and diabetic ketosis (DK) have been considered a key serious complication of diabetes mellitus. DKA and clinical feature of type 1 diabetes mellitus (T1DM);

http://www.medsci.org Int. J. Med. Sci. 2013, Vol. 10 759 however, increasing evidence indicates that DKA and subjects (control group) participated in the study DK are also common features of ketosis-prone type 2 (Table 1). In DKA group included eighteen T1DM and diabetes (T2DM) [1]. Most DKA patients require thirty-two ketosis-prone type 2 diabetes patients ac- timely treatment. Delays in the diagnosis of DKA can cording to the diagnosis criteria in document con- lead to an increase in the risk of advanced complica- cerned [2]. Patients with DKA had a plasma glucose tions and 30-day mortality. Patients with DKA are level > 13.90 mmol/L, a urine ketone level defined as generally poorly controlled prior to their admission, moderate to high (+ to +++), and an arterial pH value as reflected by high HbA1c levels [2]. Clinical studies < 7.30 at the time of admission. The criteria for DKA have demonstrated non-infectious systemic inflam- severity were previously developed: mild, 7.20 ≤ pH < mation in DKA patients, as shown by proinflamma- 7.30; moderate, 7.10 ≤ pH< 7.20; and severe, pH < 7.10 tory cytokines [3, 4] and increased peripheral white [10, 11]. blood cell (WBC) count [4, 5]. The participants underwent a routine medical It is interesting that both acute and chronic dia- examination. None of the subjects had heart failure, betic complications are correlated with elevated WBC hematologic disease, or liver or kidney dysfunction, count. There are studies indicating that an elevated and none of the patients were taking steroids. The WBC count, even within the normal range, is associ- DKA, DK, and non-DK patients received medical ated with both macro- and microvascular complica- treatment in the form of nutrition and insulin therapy. tions in type 2 diabetes [6]. Higher WBC counts may Patients with DKA and DK were monitored until be associated with the development of retinopathy, ketosis and acidosis resolved. albuminuria, and peripheral arterial disease [7–9]. Previous studies have paid much attention to proin- 2.2 Biochemical assays flammatory cytokines but little to the routine and re- Blood samples were collected into vacutainer liable WBC count. In addition, the WBC count is rou- tubes from the control and non-DK groups by veni- tinely detected in diabetic patients but does not re- puncture after an overnight fast. In the DKA and DK ceive attention from clinicians. groups, the blood samples were drawn at admission It should be stressed that previous studies only before the initial therapy and at the time of discharge provided the total leukocyte count without charac- from the hospital. terizing the differential leukocyte count in hypergly- Laboratory tests, including routine biochemistry cemic crises [4, 5]. The influence of DKA and DK on tests and arterial gas analysis, were performed us- the differential leukocyte count is poorly observed ing routine clinical assays in the hospital laboratory. and understood. The high imbalance and releasing Blood samples were collected for differential WBC characteristics of leukocytes in hyperglycemic emer- counts in tubes with EDTA and immediately pro- gencies need further study. To our knowledge, there cessed used a Mindray BC-5500 (Shenzhen, China) is no available study on the patterns or prognostic automatic blood counting system. The normal refer- value of leukocyte counts in patients with DKA and ence values for differential WBC counts are the fol- DK. Accordingly, we aimed to evaluate the changes of lowing: total WBCs 4000–10000/mm3, neutrophils total and differential leukocyte counts and the value 2000–7000/mm3, lymphocytes 800–4000/mm3, mon- by reflecting the severity of hyperglycemic emergen- ocytes 120–800/mm3, basophils 0–100/mm3, and eo- cies. sinophils 50–500/mm3. Glycated hemoglobin A1c (HbA1c) levels were 2. Methods measured using an HbA1c Meter from Bio-Rad La- 2.1 Patient recruitment and exclusion criteria boratories, Ltd. (Shanghai, China). The HbA1c test result was converted from percent HbA1c to HbA1c This study was carried out at the endocrinology in mmol/mol. and emergency department of two medical college–affiliated hospitals from January 2010 to June 2.3 Statistical methods 2012 in accordance with the principles of the Declara- The results were expressed as the mean ± SD for tion of Helsinki (2001). Ethical approval was obtained quantitative variables with normal distributions. The from the Ethical Committees of Xuzhou Medical Col- parameters of total and differential WBC counts ac- lege and Jiangsu University. The written informed cording to distribution plots and analysis of variance consent was obtained from all of the participants. homogeneity were presented as the median and the A total of fifty consecutive patients with diabetic range (min–max). A pair-wise comparison among the ketoacidosis (DKA group), 50 patients with diabetic four groups was carried out using the Tukey and ketosis (DK group), 50 diabetic patients with a stable Kruskal-Wallis non-parametric ANOVA. Mann- condition (non-DK group), and 50 normal control Whitney U analysis was used for the two subgroups

http://www.medsci.org Int. J. Med. Sci. 2013, Vol. 10 760 nonparametric test. Chi-squared tests were utilized and HbA1c: 12.64±2.95%, 11.90±2.92%, and 8.12±1.30, for the comparison of other clinical features. The cor- respectively for DKA, DK, and non-DK) than in the relations between the observed variables were ana- control group (plasma glucose: 5.12±0.21, HbA1c: lyzed by Pearson's correlation test. The risk markers 4.53±0.61%) (all p < 0.001). The glycemic variables for the diagnosis of DKA and DK were assessed by were higher in the DKA and DK groups than in the multiple logistic analysis. Receiver operating charac- non-DK group (all p < 0.05). With respect to age and teristic (ROC) curve analysis was performed to de- gender, there were no significant differences among termine the diagnostic performance of the variables. the four groups. The difference in the duration of di- Statistical analyses were conducted with SPSS 18.0 abetes did not reach statistical significance. Both the software (SPSS Inc., Chicago, IL) and MedCalc® ver- systolic and diastolic blood pressures were lower in sion 12.1.4.0. A two-tailed p value < 0.05 was consid- the DKA group and higher in the DK group than in ered statistically significant. the control and non-DK groups (p < 0.05). 3. Results 3.2 Total and differential WBC counts shown in Table 2 and 3, this study demon- 3.1 Baseline clinical and laboratory characteris- As strated a marked difference in the total and differen- tics tial WBC counts in the four groups. Of all types of The baseline demographic and clinical charac- leukocytes, the counts of total WBCs, neutrophils, and teristics of the subjects are shown in Table 1. A total of eosinophils were significantly altered with glycemic 200 cases were included in the study. There was no metabolic deterioration. However, the counts of ba- difference for the diabetic type. In DKA patients, 28 sophils and lymphocytes showed no clear difference. type 2 diabetics had acute acute respiratory infection. Acute respiratory infection increased the elevating DK and non-DK patients had no infection. There were extent of the counts of total WBC and neutrophils but 22 patients with mild DKA, 13 patients with moderate in the counts of lymphocyte basophils and eosinophil DKA and 15 patients with severe DKA. The glycemic reached no difference between infection and variables were significantly higher in the three dia- non-infection. betic patient groups (plasma glucose: 20.84±6.73 mmol/L, 15.55±2.6 mmol/L, and 9.22±1.21 mmol/L;

Table 1. Clinical and biochemical characteristics of the study participants.

Variable Control (n=50) Non-DK (n=50) DK (n=50) DKA (n=50) Female/male (n/n) 26/24 25/25 26/24 24/26 Age (years) 46.23±10.12 43.57±15.82 51.32±12.10*§ 45.05±13.25 Diabetic type (1/2) N/A 20/30 18/32 22/28 Duration of diabetes (years) N/A 4.45±1.83 4.55±2.1 4.65±2.10 Systolic blood pressure (mmHg) 130±13 138±14* 145±21** 115±6*§§†† Diastolic blood pressure (mmHg) 83±5 87±9 89±11* 78±5*§§†† Plasma glucose (mmol/L) 5.12±0.21 9.22±1.21** 15.55±2.6**§§ 20.84±6.73**§§† Glycated hemoglobin A1c (%) 4.53±0.61 8.12±1.30** 11.90±2.92**§ 12.64±2.95**§§ mmol/mol 26 65** 107±8**§ 115±9**§§ Arterial pH N/A N/A 7.41±0.12 7.10±0.12†

Serum HCO3 (mmol/L) N/A N/A 19.83±3.30 9.55±2.34†† Comparison to control group: (*) p < 0.05, (**) p < 0.001; comparison to non-DK group: (§) p < 0.05, (§§) p < 0.001; comparison to DK group: (†) p < 0.05, (††) p < 0.001. All values in the table are given as the mean ± standard deviation.

Table 2. The differential white blood cell counts in the study participants at baseline.

Variable Control (n=50) Non-DK (n=50) DK (n=50) DKA (n=50) WBCs (×/mm3) 5550 (4001–7710) 6008 (4270–7710) ** 6595 (3550–13100) **§ 13325 (4910–48790) ** §§†† Neutrophils (×/mm3) 3078 (1800–5005) 3622 (1733–5281) 4125 (1233–9503) **§ 11124 (2380–39685) **§§†† Lymphocytes (×/mm3) 1940 (1087–3814) 1889 (900–2719) 1654 (370–3741) * 1515 (301–5520) Monocytes (×/mm3) 375 (208–652) 344 (150–571) 380 (29–1044) 608 (117–3873) ** §§†† Basophils (×/mm3) 6 (0–23) 12 (0–47) ** 10 (0–41) **§§ 20 (0–215) **§§ †† Eosinophils (×/mm3) 109 (23–518) 149 (39–443) 72 (0–280) *§ 28 (0–188) **§§ † Comparison to control group: (*) p < 0.05, (**) p < 0.001; comparison to non-DK group: (§) p < 0.05, (§§) p < 0.001; comparison to DK group: (†) p < 0.05, (††) p < 0.001. All values in the table are given as the median and the range (min–max).

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Table 3. The differential white blood cell counts in DKA patients with and without infection.

Variable Non-infection (n=22) Infection (n=28) p WBCs (×/mm3) 10310 (4910–22980) 16910 (9850–48790) < 0.001 Neutrophils (×/mm3) 7560 (2380–19030) 15030 (8390–39640) < 0.001 Lymphocytes (×/mm3) 1470 (300–3260) 2206 (530–4940) 0.203 Monocytes (×/mm3) 440 (160–1480) 730 (320–3870) 0.001 Basophils (×/mm3) 15 (0–50) 20 (0–190) 0.290 Eosinophils (×/mm3) 15 (0–520) 20 (0–150) 0.851 Comparison to non-infection DKA group. All values in the table are given as the median and the range (min–max).

3.2.1 Total WBC count for basophils and eosinophil) and control (6/mm3 and 109/mm3, respectively for basophils and eosinophil) The median total WBC count increased from the groups (p < 0.05). The median eosinophil count in the non-DK group to the DKA group. The median WBC non-DK group showed no difference compared to the count was significantly higher in the DKA group control group but the basophils count was higher. (13325/mm3) than in the other three groups (p < Of all types of leukocytes, the counts of total 0.001). In the DK and non-DK groups, the median WBCs, eosinophils, and neutrophils were significantly total WBC count was significantly higher (6595/mm3 higher in severe DKA cases compared with and 6008/mm3, respectively for DK and non-DK) than mild/moderate cases (p < 0.05). However, the mean 3 the control group (5550/mm ) (all p < 0.001), although levels of plasma glucose and HbA1c showed no dif- it was still within the normal range. ference between the mild/moderate cases and severe 3.2.2 Neutrophil count DKA cases. When DKA and DK resolved after treatment, the levels of HCO3, arterial pH, and plasma The neutrophil count showed similar trends as glucose returned to normal values. Accordingly, the the total WBC count. The median neutrophil count differential leukocyte counts were significantly de- was significantly higher in the DKA group creased to within the normal range in contrast to the (11124/mm3) than the DK (4125/mm3) and non-DK levels on admission, except for an increase in eosino- 3 (3622/mm ) groups (p < 0.001). In the non-DK group, phils (all p < 0.05, data not shown). the neutrophil count was lower compared to the DK group (p < 0.05). However, there was no difference 3.3 Correlation and regression analyses between the non-DK and control groups (3078/mm3). Bivariate correlation analyses were performed to assess relationships at baseline in DKA and DK pa- 3.2.3 Lymphocyte count tients. In DKA patients, the counts of WBCs, neutro- The lymphocyte count decreased successively phils, and monocytes were significantly negatively from the non-DK group to the DKA group. However, correlated with arterial pH levels (r = −0.515, r = only one significant difference was observed among −0.510, r = −0.517, all p < 0.001, respectively) and pos- the four groups. In the DK group, the median lym- itively correlated with plasma glucose levels (r = phocyte count (1654/mm3) was lower compared to 0.722, r = 0.733, r = 0.632, all p < 0.05, respectively). the control group (1940/mm3) (p < 0.05). However, in DK patients, the total and differential WBC counts were not correlated with the arterial pH 3.2.4 Monocyte count or plasma glucose levels. The median monocyte count was significantly The linear regression analyses revealed that ar- higher in the DKA group (608/mm3) than in the other terial pH was the most significant factor affecting the three groups (p < 0.001). There was no difference total WBC count in DKA patients (β = 0.467, p = 0.003, between the DK (380/mm3) and non-DK (344/mm3) 95% CI: −45.37−10.28). Multiple logistic regression and control (375/mm3) groups. analyses with the significant clinical variables (total 3.2.5 Basophils and Eosinophil counts WBCs, neutrophils, lymphocytes, monocytes, basophils, and eosinophils) were carried out for the DKA Both basophils and eosinophil counts were sig- and DK groups respectively. The odds ratios (ORs) nificantly lower in the DKA group than in the other and 95% confidence intervals (CIs) were calculated. three groups (p < 0.05). In the DK group, the median The differences in the DKA and DK groups showed basophils (10 /mm3) and the median eosinophil no significance. Additionally, the differences in the (72/mm3) counts were significantly lower compared merged group (DKA and DK) showed no clinical sig- with the non-DK (12/mm3 and 149/mm3, respectively nificance (OR = 0.988, p = 0.005, 95% CI: 0.980–0.996;

http://www.medsci.org Int. J. Med. Sci. 2013, Vol. 10 762 and OR = 1.001, p = 0.015, 95% CI: 1.001–1.002 for eo- DK patients, the eosinophil count showed similar sinophils and total WBCs, respectively). differences in the comparison (Figure 1B). Because the total WBC and neutrophil counts 3.4 ROC analyses were significantly higher in both hyperglycemic The ROC curve for the total WBC and differen- emergencies but the eosinophil count was signifi- tial WBC counts for DKA and DK comparison is cantly lower, to examine the specific ability of the shown in Figure 1. Accordingly, the AUCs were cal- three counts in estimating hyperglycemic crises, the culated for evaluation and compared. In DKA pa- differences in the AUCs of the three counts between tients, the counts of total WBCs, neutrophils, mono- DKA and DK were calculated, and significant differ- cytes, and eosinophils showed significant differences ences were observed ( all p < 0.05) (Figure 2). but not lymphocyte or basophil counts (Figure 1A). In

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Figure 1. Comparison of the ROC plots of total and differential WBC counts with respect to their ability to reflect significant differences in the AUCs for DKA (A) and DK (B).

Figure 2. Comparison of the ROC plots of total WBC, neutrophil, and eosinophil counts between DKA and DK patients. Significant differences were found (p < 0.001, p < 0.001, p = 0.004, respectively for total WBC, neutrphil, and eosinophil).

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ies and our results, it can be concluded that these 4. Discussion proinflammatory cytokines, reactive oxygen species, The present study demonstrated that the total and adhesion molecules can derive from changes in and differential leukocyte counts were significantly leukocytes. The inflammation in the diabetic ketoaci- altered in patients with hyperglycemia from a stable dosis state is associated with the immune response in condition to ketoacidosis. Acute infection increased polymorphonuclear cells. Inflammation, as indicated the elevating extent of the counts of total WBC and by elevated total WBC and neutrophil counts, may neutrophils. Patients with ketoacidosis and ketosis play a role in the development of profound patho- had higher counts of total WBCs and neutrophils but physiology. lower counts of eosinophils compared to non-ketosis Automated measurement of the leukocyte in- diabetic patients and control subjects. Though baso- dices has many advantages, such as a lower price and phils and eosinophil counts make up a very small more convenient application from a technical per- proportion of total WBC count, receiver operating spective. Clinicians should pay more attention to characteristic curves showed that the three types of leukocyte spectrum when diabetic patients develop leukocytes (total WBCs, neutrophils, and eosinophils) significant hyperglycemia. Previous studies showed can equally reflect the presence of diabetic ketoacido- that total WBC, neutrophil, lymphocyte, monocyte sis. To our knowledge, this study dealed with a theme and eosinophil counts but not basophil count were that the existing literature data are limited. increased in T2DM patients with metabolic syndrome. Hyperketonemia with acidosis has been consid- In addition, the elevated leukocyte counts were ered an acute complication of poorly controlled or within the normal range [6–9, 16]. In our study, the newly diagnosed diabetes mellitus. The degree of median eosinophil count was 149/mm3 in non-ketosis DKA severity is significantly associated with the arte- patients and 109/mm3 in control subjects. The former + rial pH level. Higher H levels may cause leukocytes value was high but showed no significant difference. to be produced and released. In the present study, of The neutrophil count of non-ketosis patients was all types of leukocytes, the counts of total WBCs, eo- higher than in controls, although it was within the sinophils, and neutrophils were significantly different normal range. Leukocyte activation is likely to con- between the severe ketoacidosis cases and the tribute to the known increased risk of diabetic com- mild/moderate cases. The total and differential leu- plications. Both the differences between the study kocyte counts were significantly elevated in the ke- groups and the correlation were showed. To deter- toacidosis group compared with patients without mine which type cell count has significance, logistic acidosis; however, the eosinophil count was signifi- regression and ROC analysis were used. ROC analysis cantly lower in both hyperglycemic emergencies. The has the the advantage for refecting the presense. And elevated levels of ketone bodies can result in oxidative ROC analysis curve intuitively showed the value of damage, accelerated apoptosis, and the inhibition of differential cell counts, especial eosinophil count. cell growth in monocytes, which can lower the mon- Hyperglycemic crises are characterized by var- ocyte count [12]. Ketones may have a similar effect on ying degrees of the depletion of water and electrolytes the eosinophil count. Logistic regression and ROC but increased cortisol [5]. In this study, patients with analysis showed that lower eosinophil counts may be ketoacidosis had lower blood pressure. The success of a more suitable risk marker than lymphocyte, mono- the treatment is significantly correlated to the correct cyte, or basophil count for the diagnosis of ketoacido- management of rehydration, metabolic acidosis, and sis. electrolyte replacement [17]. Treatment with insulin It has been noted that diabetic ketoacidosis is had a favorable effect on the patient’s glycemic con- associated with an elevated level of active systemic trol and corrected differential leukocyte counts. These inflammatory processes and oxidative stress [3–5]. In findings suggest that diabetic ketoacidosis and ke- addition, hyperketonemia increases monocyte adhe- tosis may promote the wide range of pathophysio- sion to endothelial cells and IL-8 and MCP-1 secretion logic adaptations and changes. All these conditions in monocytes [13]. Extracellular acidosis downregu- are commonly found in hyperglycemic crises patients. lates most of the The alterations found in this study may be useful to Hemostatic platelet functions and promotes help to understand, at least in part, the pathophysi- those involved in amplifying the neutrophil-mediated inflammatory response [14]. The activation of a sub- ology of diabetic hyperketonemia. A limitation of our group of T-lymphocytes leads to the increased pro- study is that the results represent preliminary evi- duction of reactive oxygen species, cytokines, and dence from a small cross-sectional study. We did not growth factor receptors [15]. Based on previous stud- show a relationship between the differential leukocyte

http://www.medsci.org Int. J. Med. Sci. 2013, Vol. 10 765 counts and ketoacidosis complications, such as cere- 7. Moradi S, Kerman SR, Rohani F, et al. Association between diabetes complications and leukocyte counts in Iranian patients. J Inflamm Res. bral edema, pulmonary edema, and abdominal pain. 2012; 5: 7–11. It is know that DKA has already well-established di- 8. Woo SJ, Ahn SJ, Ahn J, et al. Elevated systemic neutrophil count in diabetic retinopathy and diabetes: a hospital-based cross-sectional study agnostic criterion. The demargination of neutrophils of 30,793 Korean subjects. Invest Ophthalmol Vis Sci. 2011; 52: 7697–703 as a stress response is a frequent cause of elevated 9. Papazafiropoulou A, Kardara M, Sotiropoulos A, et al. Plasma glucose neutrophils in acute medical emergencies. Leukocy- levels and white blood cell count are related with ankle brachial index in type 2 diabetic subjects. Hellenic J Cardiol. 2010; 51: 402–6. tosis is a common observation in acute illness and the 10. Rosenbloom AL. The management of diabetic ketoacidosis in children. value of utilizing this phenomenon in diagnosing Diabetes Ther. 2010; 1: 103–20. 11. Wolfsdorf J, Craig ME, Daneman D, et al. International Society for Pedi- hyperglycemic crises is very limited. To a certain de- atric and Adolescent Diabetes. Diabetic ketoacidosis. Pediatr Diabetes. gree, elevated peripheral white blood cell counts can 2007; 8: 28–43. 12. Jain SK, Kannan K, McVie R. Effect of hyperketonemia on blood mono- reflect DKA presense. We designed this study to de- cytes in type-I diabetic patients and apoptosis in cultured U937 mono- tect the ability for refecting the presense of DKA. cytes. Antioxid Redox Signal. 1999; 1: 211–20. Subclinical atherosclerosis is correlated positively 13. Rains JL, Jain SK. Hyperketonemia increases monocyte adhesion to endothelial cells and is mediated by LFA-1 expression in monocytes and with fasting glucose levels and negatively with units ICAM-1 expression in endothelial cells. Am J Physiol Endocrinol Metab. of insulin/kg/day administered in T1DM individu- 2011; 301: E298–306. 14. Etulain J, Negrotto S, Carestia A, et al. Acidosis downregulates platelet als. In addition, blood cell counts could be a putative haemostatic functions and promotes neutrophil proinflammatory re- marker for estimating both acute complication and sponses mediated by platelets. Thromb Haemost. 2012; 107: 99–110. 15. Kitabchi AE, Stentz FB, Umpierrez GE. Diabetic ketoacidosis induces in subclinical atherosclerosis [18]. Though our results vivo activation of human T-lymphocytes. Biochem Biophys Res Com- cannot replace traditional diagnostic criterion, this mun. 2004; 315:404–7. study add complementray laboratory data and the 16. Shim WS, Kim HJ, Kang ES, et al. The association of total and differential white blood cell count with metabolic syndrome in type 2 diabetic pa- patterns of total and differential leukocyte counts. tients. Diabetes Res Clin Pract. 2006; 73: 284–91. Taken together, this study demonstrated the 17. Rosenbloom AL. The management of diabetic ketoacidosis in children. Diabetes Ther. 2010; 1: 103–20. significant alteration of total and differential leuko- 18. Faienza MF, Acquafredda A, Tesse R, et al. Risk factors for subclinical cyte counts in diabetic patients with hyperglycemic atherosclerosis in diabetic and obese children. Int J Med Sci. 2013; 10: crises. It was determined that higher counts of total 338–43. WBCs and neutrophils, especially lower counts of eosinophils, should be interpreted with caution in relation to hyperglycemic emergencies. Acknowledgments We acknowledge and thank all participants for their cooperation and sample contributions. 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